Maintaining best practice in record-keeping and documentation

Module overview

This module considers best practice in record-keeping and documentation in the light of recent public inquiries and reports, renewed national interest in record-keeping standards, and the challenge of moving from paper to electronic healthcare documentation and digital storage of data. The nature of the nurse-patient relationship is also changing, and should be reflected in nurses’ record-keeping practices. Collaborative approaches to the planning and evaluation of care, and more emphasis on patients having a greater sense of ownership of information held about them should be reflected in nurses’ and other healthcare professionals’ attitudes and approaches to this aspect of practice.

Keywords

communication, confidentiality, data protection, nurse-patient relations, professional issues, record-keeping

Aims

This module aims to set the nursing practice of record-keeping in the context of recent public inquiries and guidance, as well as current policy and legislation. It discusses the risks, challenges and opportunities of electronic record-keeping. It also considers record-keeping in the context of collaborative working with patients, service users and colleagues from other professions.

Intended learning outcomes

After reading this module and completing the time out activities you should be able to:

• Describe the principles of good information governance.
• Discuss recent developments in information governance policy and practice.
• Review the quality of patients’ clinical records.
• Assess the quality of patients’ care plans.
• Identify sources of further information and guidance on record-keeping.

Introduction

Health records provide evidence about the care and treatment patients receive. They include progress notes, assessments and care plans, as well as letters written to and about patients and written communication between colleagues about patients (Figure 1). Health records are not only evidence of care, they are also clinical tools, enabling continuity of care and appropriate decision making about future care and treatment. If the quality of care provided is called into question, then health records and documents will be essential to any investigation or review.

From a governance and commissioning perspective, health records provide evidence that care is meeting quality and safety standards set and monitored by regulators, as well as the contractual requirements set by commissioners (Unite the Union 2014). The NHS code of practice for records management states that: ‘All individuals who work for an NHS organisation are responsible for any records which they create or use in the performance of their duties’ (Department of Health (DH) 2006).

Complete time out activity 1

List the guidance, policies and legislation that affect how you create and use health records. Once you have completed this module, return to this list and add any further guidance, policies and legislation of which you are now aware.

Influences on record-keeping

The quality of clinical records has been discussed in several recent serious case reviews and public inquiries. The reviews of NHS complaints (Clywd and Hart 2013) and of the Liverpool Care Pathway (Neuberger 2013) drew attention to deficiencies and difficulties faced by NHS staff in documenting care accurately. The reviews of care at University Hospitals of Morecambe Bay NHS Foundation Trust (Care Quality Commission (CQC) 2012) and Mid Staffordshire NHS Foundation Trust (Mid Staffordshire NHS Foundation Trust Inquiry 2010, Francis 2013) included critiques of record-keeping practices.

The latter found poor quality record-keeping, ‘observed too frequently to be attributable to isolated poor practice on the part of individuals’ (Mid Staffordshire NHS Foundation Trust Inquiry 2010), in the form of:

• Incomplete and inconsistent records.
• Inaccurate recording of patient information and discussions with patients and families.
• Poor recording of transfer information.

Interviews with families described lapses in information security and concerns regarding the accuracy of records about those receiving care.

The Mid Staffordshire NHS Foundation Trust Inquiry (2010) recommended that: ‘Accurate and thorough record-keeping is an essential part of the care to be provided to any patient. Without it appropriate plans cannot be made or followed through, changes in condition cannot be monitored, and continuity of care is prejudiced.’

At University Hospitals of Morecambe Bay NHS Foundation Trust, the CQC (2012) found evidence of incomplete records and drew attention to the effect of poor record-keeping on delayed discharge of patients and deterioration of patient health. There were concerns about how medical records were stored, with staff stating: ‘There is a culture within the trust of hoarding notes in small stock piles when clinical teams know that the patient will return to them in a number of weeks’ (CQC 2012).

Ward-level solutions to the systemic problem of being unable to store, locate and retrieve patient health records, namely the hoarding of notes for patients likely to re-present, were found to affect timely treatment and quality of care. The CQC (2012)recommended that the organisation improve its systems for the management of records to ensure that notes can be retrieved effectively and to reduce the risks associated with multiple temporary sets of notes.

Learning Points

1. Health records provide evidence about the care and treatment patients receive. They are not only evidence of care, but also clinical tools, enabling continuity of care and appropriate decision making about future care and treatment.
2. Health records provide evidence that care is meeting quality and safety standards set and monitored by regulators, as well as the contractual requirements set by commissioners.
3. The quality of clinical records has been discussed in several recent serious case reviews and public inquiries, which have drawn attention to deficiencies and difficulties faced by NHS staff in documenting care accurately.

Policy and guidance: recent developments

In addition to concerns about record-keeping and documentation in recent inquiries, there have been developments in policy and guidance on information governance that potentially affect nursing practice. A Guide to Confidentiality in Health and Social Care (Health and Social Care Information Centre (HSCIC) 2013) offers an up-to-date account of the duties of health and social care organisations to handle confidential information. The HSCIC was given the statutory authority in the Health and Social Care Act 2012 to lead on this issue.

Shared standards for patient records

The newly formed Professional Record Standards Body has sanctioned the shared standards for the content and structure of patient records set by the Royal College of Physicians and the Academy of Medical Royal Colleges (HSCIC and Academy of Medical Royal Colleges 2013).

These shared standards apply to:

• Referral letters.
• Inpatient notes.
• Handover communications.
• Discharge summaries.
• Outpatient letters.

These have been approved by the Royal College of Nursing, along with other medical royal colleges who are also members of the Professional Record Standards Body.

Caldicott reviews

Dame Fiona Caldicott’s second information governance review is one of the most significant developments in terms of guidance (DH 2013a). This review considered the effect of the recommendations of the first review, namely the adoption of the six Caldicott principles and the establishment of the Caldicott Guardian role (DH 1997). The original Caldicott principles set out expectations of how personal-identifiable information should be used and shared. The Caldicott Guardian is a nominated senior individual in each NHS organisation who oversees the use and sharing of personal-identifiable information.

While acknowledging the challenges faced in implementing the original Caldicott principles, the second review added a seventh principle (DH 2013a): ‘The duty to share information can be as important as the duty to protect patient confidentiality. Health and social care professionals should have the confidence to share information in the best interests of their patients within the framework set out by these principles’. Box 1 lists the seven Caldicott principles.

Box 1. Caldicott principles

1. Justify the purpose(s).
2. Do not use personal confidential data unless it is absolutely necessary.
3. Use the minimum necessary personal confidential data.
4. Access to personal confidential data should be on a strict need-to-know basis.
5. Everyone with access to personal confidential data should be aware of their responsibilities.
6. Comply with the law.
7. The duty to share information can be as important as the duty to protect patient confidentiality.

(Department of Health 2013a)

Complete time out activity 2

Who is the Caldicott Guardian in your organisation? How is that person contacted?

Learning Points

1. The Professional Record Standards Body has sanctioned the shared standards for the content and structure of patient records.
2. The first Caldicott review recommended the adoption of six Caldicott principles, which set out expectations of how personal-identifiable information should be used and shared. It also established the role of the Caldicott Guardian – a nominated senior individual in each NHS organisation who oversees the use and sharing of personal-identifiable information.
3. The second Caldicott review considered the effect of these recommendations, and added a seventh Caldicott principle.

Legal, professional and regulatory influences

Broadly speaking, nurses’ record-keeping practice should reflect an understanding of the relevant legislation and regulations, as well as national and local policy. Local NHS policies should reflect the national NHS policies on information governance, confidentiality, information security, records management and the NHS constitution (DH 2003, 2006, 2007, 2013b). At an employer level, there is a duty that all employees, including nurses, are made aware of their responsibilities under the Data Protection Act 1998 and Freedom of Information Act 2000. Activity pertaining to these two acts is overseen by the Information Commissioner’s Office (www.ico.org.uk).

Nurses working in regulated care settings should abide by standards set by the relevant regulator. For example, in England, care is regulated by the CQC under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, and nurses should be particularly aware of the stipulations of Regulation 20 (Box 2).

Box 2. Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010

Records

1. The registered person must ensure that service users are protected against the risks of unsafe or inappropriate care and treatment arising from a lack of proper information about them by means of the maintenance of:
   1. an accurate record in respect of each service user, which shall include appropriate information and documents in relation to the care and treatment provided to each service user; and
   2. such other records as are appropriate in relation to:
      1. persons employed for the purposes of carrying on the regulated activity; and
      2. the management of the regulated activity.
2. The registered person must ensure that the records referred to in paragraph 1, which may be in paper or electronic form, are:
   1. kept securely and can be located promptly when required;
   2. retained for an appropriate period of time; and
   3. securely destroyed when it is appropriate to do so.

All nurses are bound by what The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives (Nursing and Midwifery Council (NMC) 2015) says about record-keeping (Box 3). ‘Failure to maintain adequate records’ is a regularly cited allegation in ‘fitness to practise’ cases (NMC 2011). It often comes to light as a secondary concern, when potential cases of lack of competence and misconduct are being investigated.

Many of the broad themes of The Code (NMC 2015) have a bearing on nurses’ record-keeping, which include:

• Working with others.
• Respecting people’s rights.
• Upholding the laws of the land.
• Providing care that is safe and of a high standard.
• Nurse’s responsibilities regarding confidentiality, consent and information sharing.

It is also worth referring to the specific NMC (2009) guidance on record-keeping, although this does not have the same status and legal effect as The Code.

Box 3. Record-keeping in The Code

Keep clear and accurate records relevant to your practice

This includes but is not limited to patient records. It includes all records that are relevant to your scope of practice.

To achieve this, you must:

10.1 Complete all records at the time or as soon as possible after an event, recording if the notes are written some time after the event.

10.2 Identify any risks or problems that have arisen and the steps taken to deal with them, so that colleagues who use the records have all the information they need.

10.3 Complete all records accurately and without any falsification, taking immediate and appropriate action if you become aware that someone has not kept to these requirements.

10.4 Attribute any entries you make in any paper or electronic records to yourself, making sure they are clearly written, dated and timed, and do not include unnecessary abbreviations, jargon or speculation.

10.5 Take all steps to make sure that all records are kept securely.

10.6 Collect, treat and store all data and research findings appropriately.

(Nursing and Midwifery Council 2015)

Electronic records and information governance

The move towards electronic versus paper records has the potential to enhance multiprofessional working, particularly in the way that primary and secondary care services interact. The Summary Care Record – an electronic record of patients’ details relating to allergies, current prescriptions and adverse reactions to medicines – and equivalents are being introduced in the UK, enabling emergency services to access important information about patients, regardless of their location. This should enable a more integrated approach to care, and improved patient access to and ownership of personal information. However, it is important that standards and policy take into account this new way of working.

The main areas of concern for nurses in relation to information governance are:

• Consent.
• Information sharing.
• Confidentiality.

The purpose of information governance is to establish the policies and structures that regulate how data are processed to provide assurance about how organisations are managing personal-identifiable information. Such policies must take account of the risks and opportunities inherent in digital health records and electronic communication. This is particularly important because:

• Written information can be shared with colleagues in other services at the touch of a button.
• Written information can be shared with several colleagues at once.
• A digital trail indicates who accessed information and when.
• There is the possibility of accessing the health records of people for whom one is not providing direct care.

These issues were addressed in Caldicott’s review in 2013 (DH 2013a) and advice on how to handle confidential information securely was issued to organisations by the HSCIC (2013). Individual practitioners are also accountable for ensuring confidential information is handled appropriately, and this includes:

• Not sharing passwords.
• Not leaving confidential documentation unattended.
• Logging out of computers following use.
• Keeping confidential and personal-identifiable information in locked storage.
• Ensuring consent to share information is given and people know what information about them is being kept and with whom it is shared.
• Disclosing personal information only to people who have a legitimate need for it.
• Ensuring all records kept follow standards of accuracy.
• Complying with the law and local policies about information sharing and data handling.
• Using data only for the purpose for which it was given.

Equally, practitioners have a responsibility to ensure colleagues also adhere to these principles.

Learning Points

1. Nurses’ record-keeping practice should reflect an understanding of the relevant legislation and regulations, as well as national and local policy.
2. All nurses are bound by what The Code (Nursing and Midwifery Council (NMC) 2015) states about record-keeping. One of the professional standards which nurses must uphold is to “keep clear and accurate records relevant to your practice”.
3. The Summary Care Record is an electronic record of patients’ details, which enables emergency services to access important information about patients, regardless of their location. This should enable a more integrated approach to care, and improved patient access to and ownership of personal information.
4. The main areas of concern for nurses in relation to information governance are consent, information sharing and confidentiality.
5. Individuals are advised to handle confidential information securely by not sharing passwords; not leaving confidential documentation unattended; logging out of computers following use and keeping personal-identifiable information in locked storage.

How to write records

There are numerous uses for and potential readers of health records. The primary aim is to communicate accurately any observations, actions and discussions relevant to the patient or service user.

• With a move towards collaborative and shared approaches to care, both with colleagues and patients, nurses need to adopt a style of writing that suits this way of working.
• Health records should be understood by prospective readers who may not have the specific professional knowledge of the person writing the health record.
• The use of archaic terms, acronyms, abbreviations or professional jargon may confuse and unnecessarily complicate communication, particularly for lay readers.
• It is good discipline to write health records as if the patient might request to read them or professionals may be asked to rely on them as evidence in a court of law. This approach should encourage brevity and a focus on facts rather than opinions.

The standards promoted by the Professional Record Standards Body (HSCIC and Academy of Medical Royal Colleges 2013) go some way to assist collaborative working through defining content and structure of patient records. Whether these standards are adopted in the professional’s organisation or not, they will be constrained by the structures used in whatever electronic system or paper pro formas the organisation adopts. The professional does, however, have scope in the written language used to assist readers and him or herself at a later date.

Orwell (1962) discussed the use of written English to express ideas clearly and succinctly, suggesting the need to:

• Write in short sentences.
• Use simple short words.
• Avoid using jargon or abbreviations.
• Stick to the facts.

Complete time out activity 3

Look at recent entries in the case notes of one of your patients. Do they follow the guidance in this module on how to write records? If not, analyse how those entries could have been written to make them more succinct and precise.

Writing for colleagues

Nurses may be aware of the principles of good record-keeping while struggling to put them into practice. Time constraints and workload can often affect how nurses prioritise this aspect of care. However, the recording of care is not a distinct activity from delivering care, and time should be allocated for documentation as part of the patient contact.

NMC (2009) guidance on record-keeping states:

• ‘You should record details of any assessments and reviews undertaken, and provide clear evidence of the arrangements you have made for future and ongoing care. This should also include details of information given about care and treatment’.
• ‘Records should identify any risks or problems that have arisen and show the action taken to deal with them’ (NMC 2009).

This implies that where risks and safety issues have been identified, nurses have a duty to ensure they are being addressed. Putting Patients First. The Duty of Care (Public World and Unite the Union 2014) provides further clarification of how healthcare professionals can interpret their duty of care.

Increasing numbers of patients and service users have complex, multiple needs. Multiprofessional working is, therefore, essential to provide integrated care (Royal College of Physicians 2011), and this requires an increased focus on all aspects of record-keeping.

In July 2013, the HSCIC and Academy of Medical Royal Colleges published standards for the clinical structure and content of patient records, including referral letters, inpatient clerking, handover communications, discharge summaries and outpatient letters. They set out the generic headings under which patient information should be written and what should be recorded under each heading.

Care plan

Nurses communicate with colleagues about the care of their patients through care plans and progress notes. The aim of a care plan is to enable the team providing care, as well as the author of the plan, to meet the assessed needs or goals of the person receiving care. The care plan needs to be current, accurate and evidence based, with SMART (specific, measurable, achievable, realistic and timed) objectives.

Progress notes

In addition to a care plan, there needs to be a written record of the direct care provided. This will usually be in the form of progress or case notes, which may be paper or electronic. A well-constructed care plan should enable all those involved in the person’s care to write good quality progress notes. It is essential that these notes follow good record-keeping practice and reflect lawful, person-centred care. They should be explicitly linked to the individual’s care plan. The move to electronic records has led, in some organisations, to the use of generic plans.

This approach is not in keeping with the ethos of shared care planning with patients and service users. Efforts must be made to reflect the current expectation of individualisation, personalisation and collaboration in care plans, given the effect that a plan can have on subsequent care provided by other team members.

Complete time out activity 4

Look at a recent care plan you have written or one you have followed for a patient.

• Does the care plan reflect the individual’s needs?
• Does it contain information that is accurate and evidence based?
• Does the care plan use SMART objectives?
• Did the care plan enable you or members of your team to meet the patient’s assessed needs or goals?

• Writing for patients and service users

  Patients and service users are increasingly being encouraged to become involved in decisions about their health and care. This cultural change is reflected in the UK government’s health information strategy (DH 2012), arising from the ‘no decision about me without me’ approach (DH 2010). Consequently, there is a shift towards patients having access to the information that is held about them rather than healthcare professionals being in sole control.
  By 2015 in England, GP practices will be expected to offer patients access to online services, communication with the practice and personal records (Royal College of General Practitioners (RCGP) 2013). This has been piloted with patients who have long-term conditions, and along with the Summary Care Record, is considered to be of benefit to patients by increasing their ownership of their illness and information held about them (NHS 2011, RCGP 2013).
  This means that information held about people primarily belongs to them (DH 2012). Better access to health records and this shift in culture in relation to ownership, is considered to be a way of improving quality of care (NHS England 2014). However, concern that patient access and ownership presents potential risks in relation to confidentiality and data sharing has meant that the proposed data sharing initiative has recently been stalled (Cooper 2014).

  Safe storage of records

  • Patient representation groups have called for increased assurance about the safety and privacy of patient information.
  • Patients will expect healthcare professionals to be able to explain and discuss information governance with them, as well as assuming they are adhering to it in their practice.
  • Documentation should demonstrate good record-keeping practice in terms of what is written and how such information is stored and shared.

  Complete time out activity 5

  Outline the main points you would make when discussing with patients the advantages and disadvantages of sharing data from their health records as part of the NHS England (2014) Better Information Means Better Careinitiative.

  Writing for a particular service

  The information contained in health records has uses beyond direct care. It may be used as part of quality and risk monitoring, for example to inform hospital episode statistics or secondary uses service data; for public health, research and audit purposes; or for commissioning and financial decisions. It may also be used by the system regulators, for example the CQC in England, or its equivalents elsewhere in the UK – or by professional regulators as part of their investigations. Therefore, the quality of health records may have an effect on the healthcare professional, his or her colleagues and the public in the future.

  From 2014, the HSCIC in England will be publishing all nationally held clinical data, by clinical team where possible (DH 2012). Data will increasingly be used to monitor service performance and enable comparisons to be made. This means that there will be publicly available information about how specific teams are working.
• Learning Points
• 1. Health records should be understood by prospective readers who may not have the specific professional knowledge of the person writing the health record. Nurses should adopt a style of writing that suits a collaborative way of working with both colleagues and patients.
  2. It is good practice to write health records as if the patient might request to read them or professionals may be asked to rely on them as evidence in a court of law. This approach should encourage brevity and a focus on facts rather than opinions.
  3. The best way to express ideas clearly is to use short sentences, use simple words, avoid jargon or abbreviations and stick to the facts.
  4. Writing for colleagues can be in the form of care plans and progress notes. Time should be allocated for documentation as part of the patient contact.
  5. Recently there has been a shift towards patients having access to their healthcare information, to encourage them to become more involved in decisions about their care.

• Conclusions

  • Health records should demonstrate good patient care. There is a range of legislation, policy and guidance that should determine what nurses write about and how they share and store that information.
  • When creating health records, nurses should be aware of the wider audience and uses of their records.
  • Information governance practices should take account of the various approaches to electronic record-keeping, and the particular risks and opportunities associated with this way of working.
  • It is worth bearing this wider perspective in mind when negotiating for and allocating time in the working day for maintenance of documentation. It is in everyone’s best interests for this activity to be seen as a vital aspect of clinical practice.
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Acronyms

CQC: Care Quality Commission

DH: Department of Health

HSCIC: Health and Social Care Information Centre

NHS: National Health Service

NMC: Nursing and Midwifery Council

SMART: specific, measurable, achievable, realistic and timed

RCGP: Royal College of General Practitioners

Glossary

Caldicott Guardian: a nominated senior individual in each NHS organisation who oversees the use and sharing of personal-identifiable information.

Caldicott principles: recommendations of the Caldicott review which set out expectations of how personal-identifiable information should be used and shared.

Care plan: a plan, based on a nursing assessment, which aims to meet the assessed needs and goals of the patient. Care plans need to be current, accurate and evidence-based, with SMART (specific, measurable, achievable, realistic and timed) objectives.

Confidentiality: a legally protected right for patients which requires that healthcare professionals set limits on how and when patient information is disclosed. Personal, sensitive and confidential information must only be shared on a ‘need-to-know’ basis or with the patient’s authorisation.

Health record: a written form of communication that documents information relevant to the care of a patient. Health records provide evidence about the care and treatment patients receive, and enable continuity of care and appropriate decision-making about future care and treatment.

Information governance: a framework to ensure that personal information is dealt with legally, securely, efficiently and effectively, in order to deliver the best possible care. It provides a clear structure to deal consistently with the many different rules about how information is handled.

Jargon: terminology used in science, medicine, technology or other professions which is not understood by the general population.

Progress notes: notes made in the patient records which describe the patient’s condition and the treatment given or planned. Written by healthcare professionals or other members of the multidisciplinary team.

References

Care Quality Commission (2012) Investigation Report. University Hospitals of Morecambe Bay NHS Foundation Trust. CQC, London.

Clwyd A, Hart T (2013) A Review of the NHS Hospitals Complaints System: Putting Patients Back in the Picture. Final Report. The Stationery Office, London.

Cooper C (2014) Victory for Privacy as NHS Database is Delayed. tinyurl.com/o4y3s88 (Last accessed: April 15 2014).

Department of Health (1997) The Caldicott Committee Report on the Review of Patient-Identifiable Information. The Stationery Office, London.

Department of Health (2003) Confidentiality: NHS Code of Practice. The Stationery Office, London.

Department of Health (2006) Records Management: NHS Code of Practice. Part 1. The Stationery Office, London.

Department of Health (2007) NHS Information Governance: Guidance on Legal and Professional Obligations. The Stationery Office, London.

Department of Health (2010) Equity and Excellence: Liberating the NHS. The Stationery Office, London.

Department of Health (2012) The Power of Information: Putting All of Us in Control of the Health and Care Information We Need. The Stationery Office, London.

Department of Health (2013a) Information: To Share or Not to Share. The Information Governance Review. The Stationery Office, London.

Department of Health (2013b) The NHS Constitution for England. The Stationery Office, London.

Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry: Executive Summary. The Stationery Office, London.

Health and Social Care Information Centre (2013) A Guide to Confidentiality in Health and Social Care: Treating Confidential Information with Respect. HSCIC, Leeds.

Health and Social Care Information Centre, Academy of Medical Royal Colleges (2013) Standards for the Clinical Structure and Content of Patient Records. HSCIC, Leeds.

Mid Staffordshire NHS Foundation Trust Inquiry (2010) Independent Inquiry into Care Provided by Mid Staffordshire NHS Foundation Trust. January 2005 – March 2009. Volume I. The Stationery Office, London.

Neuberger J (2013) More Care, Less Pathway: A Review of the Liverpool Care Pathway. The Stationery Office, London.

NHS (2011) Clinical Use of the Summary Care Record. tinyurl.com/cdgeygu (Last accessed: April 15 2014.)

NHS England (2014) Better Information Means Better Care. NHS England, Leeds.

Nursing and Midwifery Council (2015) The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives. NMC, London.

Nursing and Midwifery Council (2009) Record Keeping: Guidance for Nurses and Midwives. NMC, London.

Nursing and Midwifery Council (2011) Annual Fitness to Practise Report: 2010-2011. NMC, London.

Orwell G (1962) Inside the Whale and Other Essays. Penguin Books, London.

Public World, Unite the Union (2014) Putting Patients First. The Duty of Care: Practical Guidance for Healthcare Staff. Unite the Union, London.

Royal College of General Practitioners (2013) Patient Online: The Road Map. RCGP, London.

Royal College of Physicians (2011) Evidence on the Quality of Medical Note Keeping: Guidance for Use at Appraisal and Revalidation. RCP, London.

Unite the Union (2014) Record Keeping and Documentation: A Guide for Health Professionals. Unite the Union, London.